If you are an existing patient needing help, we have a few options for you.
1. Use our patient portal.
2. OR – Call us at 630-371-9980
3. OR – If you are having any difficulty with the phone system, please email at PatientHelp@painchicago.com
4. OR – fill out the following form:
Please complete pain diagram and bring to your appointment. If there are any Demographic/Insurance changes or HIPAA updates, please complete and bring to your appointment. Thank you.
Forms:
- Patient Demographics
- Signature Sheet
- Pain Diagram
- HIPAA Form
- ARI Form
- Insurance Communications Consent (ICC)
- COVID 19 Consent Form
- Requisition for Forms – FMLA and Other
- Authorization for Release of Medical Records
(Please complete a request for form and fax it to our office at 630-371-1555. There is a 10 business day turnaround time) - Self Pay Policy Form
- New Patient Packet
- MR Release Form
- Curbside Office Visit Instructions
- Request Medical Records
- Benefits Assignment Policy
- ICC (Portal)
- Interventional Procedure Instructions
Policies:
- Notice of Privacy Practices
- Opioid Policy
- Controlled Substance Agreement
- Opioid Consent for Treatment
- Controlled Substance Policy
After years of bedside nursing my back was destroyed. I went through all of the steps, therapy, small surgeries, eventually a fusion. I was sent to doctor after doctor. No longer able to walk through an airport, sit at my desk, sleep through the night, carry groceries, walk the dog, bake a cake, I was so sad. I had to give up direct patient care and my life became smaller and smaller. Being very active by nature I felt like my life was pretty much over and would be spending my days reading and watching TV. I developed severe rheumatoid arthritis and my rheumatologist sent me to Dr. Glaser. With their help I can now keep up at work, enjoy my grandson's football games and travel again. I am so grateful. As a nurse I know that pain specialists often get judged because of the drugs they prescribe. This is so sad. That stigma probably prevents many people from getting the care they really need. If you have pain and you can’t live your life anymore, please get help, it is available, it is safe and it can work. Thank you to everyone at the center for giving me my life back, your patience, your dedication.
I want to "Thank You" for controlling my pain. I want to thank you for the opportunity to see my two children graduate college and then go on to achieve their master's degrees. We now live in Texas with our two children and our two grandchildren. We will be moving into our new home in about three weeks.
Learn about our 72 Hour Commitment to your pain relief.
Latest News & Events

Control Your Pain event; Summary
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